IMPORTANCIA DE LOS MICROORGANISMOS Y SU ACTIVIDAD PARA LA CALIDAD DE UN SUELO
LA DEGRADACIÓN DEL SUELO
Introduction
Several studies identify the series of self-care activities in diabetes management consisting of conducting dietary regulation, keeping physically active, adhere to the medication, performing foot care, and self-monitoring blood glucose (Toobert et al., 2000; Toljamo & Hentinen, 2001). Guidelines from both the International Diabetes Federation (IDF, 2012), and the Indonesian Endocrinologist Association (Perkeni, 2011) emphasize the importance of self-care activities to prevent the risk of complications for people with diabetes, as well as enhance quality of life. Indeed, maintaining a healthy lifestyle and establishing a normal body weight may prevent the development of diabetes as well as potential complications (DoH, 2006; WHO, 2012). Unlike established international diabetes management programs (UK or US), within Indonesia the management of diabetes is not considered a comprehensive and integrated program, with only partial recommendations into separate self-care activity for optimum diabetes care being introduced due to cost and health care structure (Sinorita et al., 2004; Soewondo et al., 2010; Soewondo, 2011). The study explored the self-care activity of people with diabetes in Indonesia and to examine whether self-care was fundamental to their diabetes management. Moreover, it sought a deeper understanding of how and if internal factors such as; self-efficacy, self-appraisal (Bandura, 1986; Heisler et al., 2003), locus of control (Wallston, 2007; Andrews et al., 2011), and external factors such as Islam religion, Javanese culture, community or social support (Koenig, 2002; Hjelm et al., 2003; Bai et al., 2009) influence the practice of self-care among Indonesian people with diabetes.
This chapter presents the overall response rate and study sample for both the quantitative questionnaire and qualitative interviews. The purpose of the Summary of Diabetes Self-care Activity (SDSCA) questionnaire and the Muslim Piety questionnaire was to explore the level of self-care activity amongst people managing diabetes attending a local hospital out-patient clinic, and compare with their level of religious devotion and practice. The idea of the two
106 questionnaires was not to recruit a representative sample for a reliable and valid result, but to gain a sufficient sample to establish some understanding of the activity of the wider diabetes clinic population with respect to self-care and religion. The wider questionnaire data informed the ‘real life’ interviews with people managing diabetes to gain a richer understanding of the opportunities and barriers for self-care management within a strong religious and Javanese culture. Whilst religion is touched on in this chapter the results of the Muslim Piety questionnaire, religious practice, devotion and self-care are the focus of Chapter Six.
Seven core themes emerged from the data that exposed the opportunities and barriers to self- care within this community and culture in Indonesia. Analysis investigates whether gender, age, education level and occupation influences self-care activity.
Levels of self-care Self-care activities
Education and knowledge Locus of control
Javanese way – sensitivity and surrender Access to health care
Health policy
First the response rate and sample characteristics will be examined. Questionnaire Response rates and sample characteristics
The response rate to the questionnaire was good; 100 people were recruited from a target population of 610 (16.4%) using a direct approach method within the diabetes clinic. Approaching people within a busy clinic environment had its drawbacks, resulting in missed opportunities to recruit some people because of the level of activity, and reduced privacy due to the number of people in the clinic waiting room. During a three month data collection period 200 approaches were made to people attending the clinic, with 105 prospective respondents identified. One person was newly diagnosed and therefore excluded and four did not return their questionnaires, resulting in a convenience sample of 100 people.
107 Of the 100 people recruited, 57 were women indicating an overall slightly higher percentage of females recruited than present in the target population registered on the hospital clinic database in 2010 (51%) (Table 5.1).
Table 5. 1 Demographic characteristics of questionnaire sample Gender (n=number of people) Age - n= (%)
18 – 39 40 - 59 ≥ 60 Male 43 1 (2.3) 26 (60.5) 16(37.2) Female 57 2 (3.5) 29 (50.90) 26 (45.6) Total Number 100 3 55 42 Occupation (n=) Private employee Pensioner Self-employed Government officer Professional Regular income Housewife Labourer Farmer Housemaid Unemployed Non-regular income 17 17 12 6 5 57 33 4 2 2 2 43 Education (n=) No formal education Elementary (primary school) Lower education level
Junior high (secondary) Senior high (College) Medium education level
Academy/University Degree
Master/ PhD – higher degree Higher education level
5 17 22 5 33 38 36 4 40
Predominantly people attending the clinic that were recruited were aged over 40 years (97%) with only 3% of the sample being aged between 18-39 years. When compared to the target population, the total people attending the clinic aged between 15-44 years was 12.31% compared with 7% of the recruited sample (aged 18-44 years), reflecting a low number of younger adults in both the target and study sample.
108 The questionnaire participants came from a variety of occupations; the majority of which identified themselves as housewives (33); others were employed in private companies (17), pensioners (17), and self-employed (12). Just less than one third (21) participants described their occupation as other, which included government officers or civil servant (6), professional (5), labourer (4), farmer (2), maid (2) and unemployed (2). The occupations were categorized into two main groups (Table 5.1); the regular income (57) and non-regular income group (43). This categorisation signifies which people had a stable and consistent source of income, as most Indonesian utilize a fee-for-service system of healthcare where people need to pay to receive a primary care services, except for those covered by the government, such as the poor, pensioner, and civil servants. Furthermore, amid the new development of health care service in Indonesia into a more insurance-based system, which required the people who are not eligible to be covered by the government to pay a monthly premium, has given the need to have a sufficient income in order to be able to have a sustainable health care service. Thus, the notion of having a regular and sufficient income is important particularly among people with a long term condition, such as diabetes, to establish sustainable healthcare delivery.
Levels of education were categorized into six items: no-formal, elementary (primary school), junior high (secondary education), and senior high (College), Academy/University degree, and Master/PhD a higher degree. There were participants recruited across all education levels; low (22) medium (38) and high (40), with more individuals higher educated.
Interview response rate and sample characteristics
Questionnaire participants were asked to complete a reply slip to identify if they would be happy to be interviewed. From the reply slips, initially it was envisaged that interview participants would be identified from a pool of people falling into one of four groups based on the high or low level of self-care and high or low level of religiosity, drawing 5-6 people random from each grouping (Table 5.2).
109 Table 5. 2 Four categories of self-care and religiosity
Highly religious - high self-care Low religiosity - high self-care Highly religious - low self-care Low religiosity - low self-care
However, in reality only 25 of the 100 people completing questionnaires agreed to be interviewed and one person was excluded because he was newly diagnosed. The majority of these people rated themselves as highly religious and high self-care so the quota sampling method was not applied resulting in all participants that came forward being interviewed (Table 5.3).
Furthermore, the categorization into two groups of high and low was proven to be unadvantageous in revealing the true nature of the level of self-care and religiosity among the participants. Therefore, as seen in Table 5.6, the categorization was adjusted into three level of high, moderate and low, which then, shows the majority of participants are in the moderate groups.
Table 5.3 Interview sample characteristics (N=24)
Gender Age groups Education level Income
Male 10 18 – 39 2 Higher 8 Regular 15
Female 14 40 – 59 14 Middle 10 Non-regular 9
>60 8 Lower 6
Within the interview sample there were 14 females and 10 male participants, who predominantly were over 40 years of age and of middle to higher education levels, although there was a spread of characteristics throughout the sample allowing different aspects such as low non-regular income, education level, age and gender to be explored within the data findings. To gain a deeper understanding of the context surrounding individual participants Table 5.4 provides a more detailed overview,
110 pseudonyms are used to maintain anonymity among the participants, as well as the physicians.
111 Table 5. 4 Contextual information about the interview participants
Name Age yrs Occupation Family Context
1. Mr Adil 56 Business
owner
University graduated; living with his wife and four children.
2. Mr Arif 42 Business
owner
University graduated; living with his wife and two children.
3. Mrs Asti 77 Housewife Graduated from senior high school; living with a maid in a large property; building a house inside the property for her daughter; children are university graduates; tends to be solitary from social activity.
4. Mrs Eva 39 Admin officer University graduated; works in private company, living with her husband who works in the same company, four children, nephew and mother in-law.
5. Mr Fajar 39 Workshop
Mechanic
Graduated from senior high school; living with his wife, no children, his brother who works as a cleaner, and parents-in-law.
6. Mrs Heti 47 Admin officer University graduated; works in private University, living with her husband and three children.
7. Mrs Ismi 71 Retired
teacher
Graduated from senior high school a college graduated in Islamic teaching; living with her daughter (a nurse in PKU) and her family, used to be a member of Persadia.
8. Mr Jawen 64 Unemployed
truck driver
Lives with his wife, who has been the breadwinner since he is ill, nephew and his older sister in urban area; acclaimed himself as a Kejawen* and no longer practising Islam.
112 9. Mr Kasi 88 Retired Senior high school graduated; Retired from the Police force as an auditor in
the inspectorate division; Living in the city with his wife; children are university’s graduates with good social and economic status.
10. Mr Makmur 58 Business owner
Senior high school graduated; living with his wife and three children.
11. Mrs Maryam 60 Business owner
University graduated; Living with her husband and a daughter age of 25 years old.
12. Mr Ripan 48 Labourer Graduated from elementary school; living with his wife who is running a food stall and his two children; has a higher level of religiosity and self-care. 13. Mr Sadi 48 Civil servant University graduated; living with wife and his 12 years old son. 14. Mrs Santi 56 Business
owner (ran from house)
Senior high school graduated; living with her husband and three children, two still in education, a member of Persadia; a breadwinner since her husband has a non-regular job
15. Mrs Sati 60 Retired civil servant
University graduated; living with her husband, who works as a silversmith, and a daughter, a fifth semester university student.
16. Mrs Sifa 62 Retired teacher
University graduated; living with her husband in a rural area of Yogyakarta
17. Mrs Siti 50 Housewife Graduated from primary school; used to work in the market, but giving up after the illness; living in the area of Keraton settlement in a small house with her husband and three children; husband works in an irregular job as a seasonal batik tulis (handmade) instructor, dependent on children for support
113 18. Mr Sujawi 47 Foreman in
textile factory
Graduated from senior high school; Living in a rural area of Jogjakarta with his wife and children; the wife is a mu’alaf (a convert) works with the police force; he used to be practicing Kejawen* and still holds the value and several teachings of it.
19. Mrs Suti 46 Housewife no formal education; used to work supporting her husband in cleaning cement sacks and selling it in the market; living in a small house in sub-urban of Yogyakarta with her husband and a son who is at university; has a daughter who married and lives in different city.
20. Mr Suyono 63 Retired civil servant
University graduated; living with his wife and a 30 years old son who is running a small family’s shop. He sometimes works as a mining consultant in a remote area.
21. Mrs Swasti 45 PKU nutrition dept
Senior high school graduated. Living by herself.
22. Mrs Tata 58 Housewife Graduated from elementary school; living with her son and his wife and three children.
23. Mrs Umi 57 Housewife Junior high school graduated; living with her husband who a retired from an oil company, and three children.
24. Mrs Wati 57 Housewife Senior high school graduated; living with a husband, who is running a law firm, three children and two nephews, member of Persadia.
114 Findings
Self-care findings are presented within seven core themes and a number of sub-themes. The data of perceived levels of self-care and activities are explored for the whole sample and the interview participants. Throughout the themes qualitative data complements the quantitative evidence providing in-depth explanations for some results or identifying influencing factors. This is particularly evident in the explanations of the influencing factors on an individual’s locus of control that enables or disables them from undertaking self-care activities (Table 5.5)
Table 5. 5 Themes of emerging findings
Perceived levels of self-care
Activities of self-care
o Taking medication to manage diabetes
o Managing a healthy diet
o Physical exercise
o Self-monitoring of blood glucose
o Foot care
Education and knowledge
o Lack of structured education
o Sources of information
o Persadia: an education source and support
Locus of control
o Being in control
o Poor control and lack of responsibility
o Letting others take control or share control
Javanese way – sensitivity and surrender
Peace of mind and role of Allah
Poor access to health care Issues with the SDSCA questionnaire
Each theme is presented in turn; then an additional theme examines the issues with the translated SDSCA captured within the findings and the partially implemented gold standard guidelines for diabetes management in Indonesia that influences opportunities for self-care. Perceived levels of self-care
Perceived levels of self-care are captured within the first part of the SDSCA questionnaire which asked participants to identify how often they partake in self-care activities, with respect to diet medication, physical exercise, foot care and blood glucose monitoring. This theme presents the overall self-care levels of the whole sample and the interview participants to gain an
115 understanding of whether self-care in diabetes management is an accepted and practised concept in this cohort of patients, and what activities are considered core diabetes management. An SDSCA questionnaire scores the responses to items on the questionnaire (Appendix 9) and the low, moderate and high categories were determined by dividing the scores into three approximate groups (low=7-37, moderate=38-68, high=69-98) (Table 5.6).
Table 5. 6 Levels of self-care
Whole sample (n=100)
Interview sample (n=24)
Overall level of self-care
high moderate low high moderate low
11 78 11 4 16 4 Self-care/ gender Male Female 6 5 33 45 3 8 2 2 7 9 1 3 Self-care/ age 18-39 40-59 >60 0 6 5 2 40 36 1 9 1 0 1 3 1 10 5 1 3 0 Self-care/ education Higher Medium Lower 4 6 1 34 27 17 2 5 4 2 1 1 5 7 4 1 2 1 Self-care/ income Regular Non-regular 7 4 44 34 9 2 2 2 11 5 3 1
Out of 100 participants, 11 participants perceived themselves to have a high level of self-care, reporting regular activities of self-care for some items, compared to 78 who indicated moderate self-care activity, and a further 11 who performed less self-care activities or less regular self-care. In the whole sample there was more men (6) reported higher self-care than women (5) and more women (8) reported lower levels of self-care than men (3). The majority of both men and women, across all age groups reported moderate levels of self-care (Table 5.6). People with a lower education level were more evident in the low self-care group and people with a higher education level in the high self-care group. Interestingly, more people with a regular income (9) reported a lower level of self-care than those with a non-regular income (2). A similar pattern of self-care activity to the whole sample was identified across the interview participants with moderate self- care activity being reported.
116 According to the SDSCA questionnaire findings people in Indonesia perceive themselves to have a moderate level of self-care for their diabetes chronic disease management. However, exploration of peoples ‘real life’ experiences from within the interviews and more detailed analysis of the activities of self-care provide a deeper insight of the reliability of the self- assessment instrument within this sample group.
Activities of self-care
The levels of self-care can be explored through the different activities of the questionnaire to identify which activity is performed most regularly by the sample participants, which includes adhering to medication, following a recommended diet, taking physical exercise, foot care and self-monitoring of the blood glucose. An overview of all activities are presented for the whole sample then each activity is examined in more detail to identify if different people characteristics influence the activity performed and using narrative data from the interviews to better understand the issues people have with the recommended diabetes self-care activities.
From the questionnaire data participants reported that the most frequent self-care activities they were inclined to perform involved taking their medication (M=88%) and following a recommended diet (D=84%) to ensure their blood glucose remains stable (Figure 5.1).
Figure 5. 1 Perceived self-care activity (whole sample n=100)
Physical activity was identified by only half of participants (PA=50%), with foot care (FC=44%) and self-monitoring of blood glucose (SMBG=16%) being the least performed self-care activity (Figure
84 50 16 44 88 0 10 20 30 40 50 60 70 80 90 100 Diet PA SMBG FC Med %
117 5.1). Similar to the results from the whole population, the 24 participants for the interviews were more inclined to take medication (80%), although less were inclined to strictly manage their diet (67%), more were inclined to undertake physical activity (57%), more inclined to perform foot care (49%), and comparable self-monitoring blood glucose (13%) (Figure 5.2).
Figure 5. 2 Perceived self-care activity (Interview participants n=24)
Taking medication to manage diabetes
Taking medication for many was seen as integral to managing diabetes. The questionnaire results suggest that the majority of people are inclined to follow the recommended diabetes medication plan from the doctors, whether this is insulin or tablets (such as Metformin) (Figures 5.3 and 5.4). This was not influenced by gender, age, regular income or education level.
67 57 13 49 80 0 10 20 30 40 50 60 70 80 90 100 Diet PA SMBG FC Med %
118 Figure 5. 3 How many of the last seven days did you take your recommended insulin injections? (Whole sample n=100)
Figure 5. 4 How many of the last seven days did you take your recommended diabetes pills? (Whole sample n=100)
Placing importance on medication was reinforced within the interview participant’s questionnaire responses (Figure 5.5).
Figure 5. 5 Interview participants medication self-care activity (number of days) (n=24) 9 1 1 1 1 2 1 84 0 20 40 60 80 100
never 1 day 2 days 3 days 4 days 5 days 6 days 7 days
% 6 4 0 1 1 2 0 86 0 20 40 60 80 100
never 1 day 2 days 3 days 4 days 5 days 6 days 7 days
% 2 1 0 0 1 1 0 19 2 0 0 0 1 1 0 20 0 5 10 15 20 25 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
recommendation medication oral or insulin recommendation
N